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  • Final Outpatient Payment Rule From CMS Eases Supervision, Moves Ahead With 'Site Neutral' Payment Despite Lawsuit

    In this review: Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs (final rule)
    Effective date: January 1, 2020
    CMS Fact Sheet

    The big picture: Continued trends toward easing supervision burdens, and a contested effort to reduce payment variation (that doesn't really affect PTs)
    The US Centers for Medicare and Medicaid Services (CMS) is pushing for an outpatient environment in which overall payments vary less according to who owns a facility, according to the final Medicare outpatient payment system rule set to go into effect on January 1, 2020.

    The rule moves ahead with CMS efforts to establish a "site neutral" payment model in its payment for physician services, doing away with a system that pays so-called "off campus" hospital-owned facilities more than it does their independent equivalents. The plan hit a recent snag when a federal judge refused to impose a stay on a court ruling in September in favor of plaintiffs, including the American Hospital Association, that sought to block the rollout of the site-neutral plan. CMS stated in the final rule’s fact sheet that they do not believe “it is appropriate at this time to make a change to the second year of the two-year phase-in of the clinic visit policy. The government has appeal rights, and is still evaluating the rules and considering, at the time of this writing, whether to appeal from the final judgment.” Because physical therapy services in outpatient settings are paid under the CMS physician fee schedule, PTs aren't affected by CMS' hoped-for change.

    The final rule also includes an APTA-supported move toward easing supervision burdens placed on hospitals by way of changed supervision requirements for outpatient therapeutic services in all hospitals. Beginning January 1, the requirements will move from "direct" supervision to "general" supervision, meaning that while a given procedure may be furnished under a physician's overall direction and control, the physician's physical presence no longer will be required during the performance of the procedure. The change is viewed as a particularly positive one for critical-access hospitals and other facilities in underserved areas.

    Also notable in the final rule

    • Payment rates for outpatient hospitals and ambulatory surgical centers (ASCs) will increase by 2.7%.
    • CMS said it will consider the stakeholder feedback it received on its proposal to add 4 safety measures to the Outpatient Quality Reporting Program (Hospital OQR Program) in the future. These measures already are required of ASCs: patient falls, patient burns, wrong site/side/procedure/implant, and all-cause hospital transfers/admissions.
    • CMS recognized that it received over 1,400 comments regarding its proposal to require hospitals to make their standard charges public for all items and services, and stated that it would summarize and respond to these comments in a future final rule.

    Worth watching: prior authorization
    Prior authorization also figures into the new rule, which requires preapproval for 5 cosmetic procedures including vein ablation. While this doesn't directly affect services associated with physical therapy, APTA advocates in general against prior authorization requirements that slow the delivery of care and limit patient access to appropriate interventions. APTA regulatory affairs staff will continue to pay particular attention to future rulemaking in this area.

    Final DMEPOS Rule Attempts to Shape a Clearer, More Predictable System

    In this review: Medicare Program: Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Amounts, DMEPOS Competitive Bidding Program (CBP) Amendments, Standard Elements for DMEPOS Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements (final rule)
    Effective date: January 1, 2020
    CMS Fact Sheet

    The big picture: A rule that attempts to keep up with the rapid development of new and different DMEPOS
    The US Centers for Medicare and Medicaid Services (CMS) aims to make payments for devices a little more predictable in light of the ever-increasing—and ever-advancing—range of options available to providers and patients. CMS intends to accomplish this goal by way of a "comparable item analysis" system that the agency thinks will help make it easier to nail down exactly what Medicare will pay for those devices. The new rule takes effect January 1, 2020.

    The idea is that when old and new items are comparable, CMS will use the fee schedule amounts for the existing older item to determine payment amounts for the new one. If there are no comparable older items, CMS says it will base payment on commercial pricing data such as internet pricing and supplier invoices. Those prices for the noncomparable items won't necessarily stay fixed: if commercial pricing drops, so will CMS rates. CMS identified 5 main categories upon which new DMEPOS items can be compared with older ones: physical components, mechanical components, electrical components (if applicable), function and intended use, and additional attributes and features.

    Also notable in the final rule

    • CMS is revamping requirements around face-to-face meetings between providers and patients in need of DMEPOS that "may have created unintended confusion for stakeholders." The current requirements—essentially a collection of ad-hoc provisions that have accrued over the past 13 years—will be replaced with what CMS describes as a "single list of DMEPOS items potentially subject to a face-to-face encounter and written orders prior to delivery, and/or prior authorization requirements."
    • CMS will no longer require contract suppliers to notify CMS 60 days in advance of a change of ownership (CHOW). Instead, CMS will require notification no later than 10 days after the effective date of the CHOW. Additionally, CMS is removing the distinction of a “new entity,” but the rule retains the successor entity requirements.